Lodge at Grand Junction, the

"12.2.2 Infection Control Officer Each facility shall assign at least one (1) staff member responsible for the site management of the facility' s Infection Prevention and Control Program and training. This individual shall be responsible for the following: (1) (2) Completing an infection prevention and control training from a nationally recognized provider or the Department' s training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type."Based on record review and interview the residence failed to assign at least one staff member responsible for the site management of the residence' s Infection Prevention and Control Program and who had completed an infection prevention and control training two weeks after designation, af.. A relicensure survey with complaint #CO29987 was completed on 10/1/24. Deficiencies were cited. Based on observation, record review and interview, the residence failed to have readily available a roster of current residents which included the residents' emergency contact information and a diagram of the residence that showed room location, affecting 48 current residents. Findings include: On 10/1/24 at 7:30 a.m., the residence' s official resident roster was requested. The roster included the full names of the residents and their room numbers. The resident roster did not include emergency contact information for the residents nor a diagram of the residence. On 10/1/24 at 4:45 p.m., the administrator stated she was unaware of the required components of the resident roster. The administrator added that she had a book of face sheets that could be provided in the event of an emergency tha.. Based on record review and interview, the residence failed to ensure its emergency policies addressed written agreements with other facilities or community agencies in the event of the relocation of residents, affecting 48 current residents. Findings include: Review of the residences' undated temporary relocation procedure policy read "The (residence) has agreements with the relocation sites indicated on the following pages." The following pages had blank spaces to insert the required information. The policy further read "The residence will establish a relationship with appropriate transportation companies," and "The residence has agreements with the following suitable transportation companies." There were no documented agreements with transportation companies. On 10/1/24 at 10.. Based upon record review and interview, the residence failed to ensure medication cart audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 48 current residents.Findings include1. ReferencesThe residence' s 12/1/23 medication records policy read in part that medication records would be audited on a quarterly basis. On 10/1/24 at approximately 9:30 a.m., the controlled substance list was requested and not received during the onsite visit. On 10/1/24 at approximately 1:40 p.m., documentation of quarterly medication audits were reviewed, and there was no evidence that the administrator participated in the audit. 2. Interviews On 10/1/24 at approximately 1:40 p.m., the resident care coordinator stated ..

A licensure revisit was completed on 10/1/24 for the previous deficiency cited on 4/26/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Tag 10.1 was not cited in the previous event; however, the deficiency was included in the previous event' s informational 999 tag. Based on observation, record review and interview, the residence failed to have readily available a roster of current residents which included the residents' emergency contact information and a diagram of the residence that showed room location, affecting 48 current residents. Findings include: On 10/1/24 at 7:30 a.m., the residence' s official resident roster was requested. The roster included the full names of the residents and their room numbers. The resident roster did not include emergency contact information for the residents nor a diagram of the residence. On 10/1/24 at 4:45 p.m., the administrator stated she was unaware of the required components of the resident roster. The administrator added that she had a book of face sheets that could be provided in the event of an emergency that had the required emergency contact information. She acknowledged the resident roster was missing the residents' emergency contact information and a diagram of the residence. The administrator stated this deficiency that was previously an informational tag was not corrected due to lack of oversight and knowledge of the required components of a resident roster. Based upon record review and interview, the residence failed to ensure medication cart audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 48 current residents.This deficiency was cited previously during a state licensure survey 8/18/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include1. ReferencesThe residence' s 12/1/23 medication records policy read in part that medication records would be audited on a quarterly basis. On 10/1/24 at approximately 9:30 a.m., the controlled substance list was requested and not received during the onsite visit. On 10/1/24 at approximately 1:40 p.m., documentation of quarterly medication audits were reviewed, and there was no evidence that the administrator participated in the audit. 2. Interviews On 10/1/24 at approximately 1:40 p.m., the resident care coordinator stated she often completed medication cart audits; however, the administrator did not participate on a quarterly basis. On 10/1/24 at 4:45 p.m., the administrator stated she oversaw all aspects of the residence but felt quarterly medication audits did not need to be completed by the administrator in case of probable liability issues with medications. The a..